ineffectiveness or difficult of this treatment led surgeons to often consider internal fixation. 3 This therapeutic option is difficult to perform in patients with severe associated injuries, significant pulmonary contusions or, simply, in elderly or unhealthy patients. 4 In truth, the therapeutic principle of the external traction of soft tissue was described in literature more than fifty years ago. 5–7 Although our patient met the definition for a flail chest, the segment in this setting is over the area of the mediastinum and not the pleural cavity. Thus, it is likely that this patient did not require formal stabilization because there was no negative pressure transmitted to the segment. But it is however, in our opinion, a very unusual observation that the negative pressure from a VAC dressing, without rigidity, would result in sufficient fracture reduction. The unexpected results on the chest deformity, such as the significant increase of the space between second rib end and pulmonary trunk and the regularization of the rib fractures, draws attention to the possible application of negative pressure as a new thoracic therapy in flail chest and, in general, on fracture reduction. We are aware that further targeted clinical trials will be necessary to confirm our report and to determine this issue but we would like to know Your opinion and that of the International Expert Panel on Negative Pressure Wound Therapy. It could be a new therapeutic horizon for negative pressure wound therapy? Conflict of interest The authors declare that they have no conflict of interest. References 1. Runkel N, Krug E, Berg L, et al. Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: step towards an international consensus. Injury 2011;42:S11–2. 2. Orgill DP, Manders EK, Sumpio BE, et al. The mechanisms of action of vacuum assisted closure: more to learn. Surgery 2009;146:40–51. 3. Nirula R, Mayberry JC. Rib fracture fixation: controversies and technical chal- lenges. Am Surg 2010;76:793–802. 4. Hauser CJ. Livingstone DH., Pulmonary contusion and flail chest. In: Asensio JA, Trunkey DD, editors. Current therapy of trauma and surgical critical care. Phi- ladelphia, PA: Mosby, Inc.; 2008. pp. 269–77. 5. Jones TB, Richardson EP. Traction on the sternum in the treatment of multiple fractured ribs. Surg Gynecol Obstet 1926;42:283–5. 6. Jaslow IA. Skeletal traction in the treatment of multiple fractures of the thoracic cage. Am J Surg 1946;72:753–5. 7. Hudson TR, McElvenny RT, Head JR. Chest wall stabilization by soft tissue traction: a new method. JAMA 1954;156:768–9. Marzia Salgarello Damiano Tambasco* Eugenio Farallo Department of Plastic and Reconstructive Surgery, Catholic University of ‘‘Sacro Cuore’’ – University Hospital ‘‘A. Gemelli’’ – Largo A. Gemelli 8, 00168 Rome, Italy Giancarlo Savino Lorenzo Bonomo Department of Radiology, Catholic University of ‘‘Sacro Cuore’’ – University Hospital ‘‘A. Gemelli’’ – Largo A. Gemelli 8, 00168 Rome, Italy *Corresponding author. Tel.: +39 06 30154849; fax: +39 06 30154849 E-mail address: damtam@hotmail.it (D. Tambasco). doi:10.1016/j.injury.2011.03.060 Letter to the Editor Re: The invisible nail: A technique report of treatment of a pathological humerus fracture with a radiolucent intrame- dullary nail [Injury 2011;42:424–6] Dear Sir/Madam, We read with interest the article ‘‘The invisible nail: A technique report of treatment of a pathological humerus fracture a radiolucent intra medullary nail’’. We would like to highlight certain shortcomings of this nail. The most important one is that it is uncannulated and fracture site has to be opened to reduce the fracture and the nail is passed in anantigrade manner. There is a potential for seeding of tumour especially if it is a solitary tumour and we are not sure about the diagnosis. By opening the fracture site we are disturbing the fracture haematoma and interfering with bone healing – hence on one hand this nail helps in assessing healing and on other it theoretically delays healing. We are not sure about radio lucent intra medullary nail having the potential to enhance clinical follow up of bone healing, and hence improve overall clinical outcome. As per the British Orthopaedic Oncology Society (BOOS) guideline the aims of surgery are to relieve pain and restore function. The surgeon must assume that the fracture may not unite. 1 The overall fracture healing rate for pathological fracture is 35%for patient living for 6 months and 74% in patients who survive longer than six months. 2 There are studies which suggest that patients treated with cemented intramedullary nailing had better pain relief, less use of analgesics and better functional restoration immediately after surgical procedure when compared to the patients without cement fixing. The rate of complication did not differ between these two groups. With this invisible nail we do not have this option as well. 3 Fig. 8. VR 3D reconstruction of the second CT scan, performed after VAC application, showing a better alignment of fragments of third, fourth and fifth anterior rib arch. Data were acquired using a 64-slice MDCT (GE Healthcare, Milwaukee, WI, USA). Letters to the Editor / Injury, Int. J. Care Injured 42 (2011) 1387–1391 1390